Toxic epidermal necrolysis

Background

  • Explosive dermatosis with tender erythema, bullae, and subsequent exfolliation
  • Most commonly caused by medications

Clinical Features

  • Malaise, anorexia, myalgias, arthralgias, fever, painful skin, GI symptoms
  • Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms
  • Exam with warm tender erythema with overlying flaccid bullae, erosions with exfoliation
  • Positive Nikolskly's sign (able to rub off superficial layers of skin with pressure)
  • Mucosal involvement (oral, conjunctival, respiratory, GU)
  • Systemic toxicity
  • 25-35% Mortality
    • Death is usually caused by infection, hypovolemia, and electrolyte disorders
  • Predictors of poor prognosis include: age, extent of disease, leukopenia, azotemia, and thrombocytopenia

Differential Diagnosis

Erythematous rash

Evaluation

  • History of drug exposure
  • Prodrome of malaise and fever
  • Positive Nikolsky sign
  • Oral, ocular, and/or genital mucositis with painful erosions
  • Necrosis and sloughing of the epidermis
  • Diagnosis is made my skin biopsy
  • SJS vs TEN
    • SJS - skin detachment of <10% of BSA
    • TEN – skin detachment of >30% of BSA

Management

  • Monitor cardiopulmonary status closely
  • Correct fluid and electrolyte imbalances
  • Attend to infectious complications

Disposition

  • ICU
  • Best cared for in a burn unit
  • Immediate derm consult

References

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